Role of Biopsy in Selecting Candidates for AS

Beyond the Abstract - The role of biopsy core number in selecting
prostate cancer patients for active surveillance, by Guillaume
Ploussard, MD and Alexandre de la Taille, MD

The inclusion of patients in AS protocols emphasizes the necessity of
accurate staging strategies. Should all patients submitted to prostate
biopsy be ...subjected to an extensive biopsy strategy? Only prospective
studies comparing biopsy inclusion criteria and biopsy-core number for
AS protocols and comparing AS with immediate radical treatment would be
able to clarify the best candidates for AS according to outcome in
terms of rising PSA and specific deaths. Clinicians, however, clearly
have to deal with the biopsy-core number for treatment decisions and
patient information.Read More

Watchful Waiting for older Men

Watchful Waiting Works for Older Men With Prostate Cancer But experts stress the same does not hold true for patients under 60 By Ed Edelson Tuesday, Sept. 15 (HealthDay News) -- Older men diagnosed with prostate cancer who choose watchful waiting are doing better these days than in the era before screening with a test for prostate-specific antigen (PSA) became common, a new study finds. "The most important message is that the long-term outcome for patients who don't have surgery or radiation is pretty good," said study author Dr. Grace L. Lu-Yao, an associate professor of medicine at the University of Medicine and Dentistry of New Jersey. Her report appears in the Sept. 16 issue of the Journal of the American Medical Association. That message applies only to men over 65 when prostate cancer is diagnosed. Lu-Yao and her colleagues analyzed data on 14,516 such men whose diagnoses were made between 1992 and 2002, at an average age of 78, and who did not have surgery or radiation in the next six months. The researchers followed them for an average of 8.3 years. The study separated men by their Gleason score, which measures the degree to which the prostate gland has lost its orderly structure. Greater disorder indicates greater danger from the cancer. The 10-year death rate from prostate cancer was 8.3 percent for men with the least disordered tumors. Their death rate from all other causes was 59.8 percent. For men with moderately disordered tumors, the 10-year prostate cancer-specific death rate was 9.1 percent, compared to a 57.2 percent death rate from all other causes. The prostate cancer death rate for men with the most disordered tumors was 25.6 percent, compared to 56.5 percent for all other causes. The cancer survival numbers are much better than for the pre-PSA screening era, possibly because "patients now are diagnosed at a much earlier stage compared to patients 10 and 20 years ago," Lu-Yao said. Earlier detection translates to apparent longer survival simply because the cancer has a longer time to grow. But the information in the study shouldn't be applied to younger men, Lu-Yao stressed. The best available data indicate better survival with treatment for men under 65, she said. So, the study might send the wrong message about PSA testing to those men, said Dr. Richard Greenberg, chief of urologic surgery at the Fox Chase Cancer Center in Philadelphia. "My concern is that 50-year-old men with family histories of prostate cancer will be listening to these statements that there is too much screening, so they won't have screening because they think it isn't necessary," Greenberg said. He is skeptical about watchful waiting, except in carefully selected cases. "I don't think anyone under 60 is a great candidate for watchful waiting unless they have another condition that is going to do them in within 10 years," Greenberg said. Every man diagnosed with prostate cancer should understand that watchful waiting is one possible option, he said. "But you have to individualize the decision for every patient," Greenberg said. "If they have an aggressive cancer, they should be treated aggressively. You need to be very selective when you say when a conservative approach is appropriate." Treatment or watchful waiting for cancer in men 70 and older "is an important question, but probably not the most important question," said Dr. Martin Sanda, director of the prostate cancer center at Beth Israel Deaconess Hospital in Boston. Sanda recently reported a study of younger men whose average age when they were diagnosed with prostate cancer was about 60. That study indicated that "lower-risk tumors probably can be managed with watchful waiting in men anywhere from the 40s to the 70s," Sanda said, but the key issue is the nature of the tumor. "For patients with poorly differentiated tumors, there is a fair amount of cancer deaths unless they are treated aggressively," he said. More definitive information about watchful waiting versus treatment of prostate cancers is expected from a study recently started in Canada and now being done in medical centers there and in the United States, Greenberg said. But results of that study are not expected for at least 10 years, he noted, and meanwhile men and their doctors need to make treatment decisions based on each man's characteristics. "We need to individualize these decisions, even in the elderly," Sanda said.

Why Avodart and Peoscar(Finasteride are Ignored?

Studies’ Complications

Then came the studies of finasteride and dutasteride for prostate cancer. The drugs block the conversion of testosterone to dihydrotestosterone, a hormone that prostate cancers need to grow. They are on the market to shrink the prostate in older men, whose prostates often enlarge. (Finasteride is also sold to grow hair — but the dose is one-fifth the dose that shrinks prostates and that dose has not been tested for cancer prevention.) Doctors can prescribe the drugs for cancer prevention but, at this point, that is not on their label.

The prostate cancer studies were complicated by other another factor; at first, researchers thought, erroneously, that finasteride was actually spurring the growth of aggressive prostate cancers. The drug’s side effects can include impotence or decreased ejaculate. But the Food and Drug Administration concluded that these effects, if they occur at all, are gone after a year.

Now, even though the F.D.A. deemed the drug’s adverse reactions to be “usually mild and transient.” The American Urological Association and the American Society for Clinical Oncology recommend that men 50 and older consider taking it. But there appears to be little interest even among high-risk men.

Importance of PSA Screening

From the latest research, here are seven reasons why urologists are encouraging men of any age who expect to live at least another 10 years to think hard about getting a PSA test, even if they have to pay out of pocket:

1. Keeping tabs on PSA saves lives. Many urologists flat out reject a large study published in the New England Journal of Medicine earlier this year that found men who got the PSA test did worse than men who didn't. The dissenters say the results weren't trustworthy—many of the men who weren't supposed to get tested actually did, thanks to their proactive primary-care docs. Another recent large NEJM study found that nine years after entering the study, men who got regular PSA screening were 20 percent less likely to die of prostate cancer. One model suggests the PSA test has contributed to much of the 30 percent decline in prostate cancer deaths seen in recent decades.

2. There's no magic PSA number. In the urologists' latest recommendations, it is clear that there's no one-size-fits-all age at which to be tested or bad PSA number. For many years, a particular reading of 4 or above was a battle cry that called for a biopsy or aggressive treatment. In reality, any reading is suspect. Without knowing much more about him, studies give a middle-aged man a 10 percent chance of having visible cancer on biopsy even if his PSA level is zero. Today, doctors consider a single PSA number in the context of your specific health background, race, and family history (it may also help diagnose benign enlargement or an infection), and then suggest when to be tested next. If you do get a biopsy, the criteria for serious concern are stricter, and there are more conservative treatment options.

3. Velocity matters. Your first PSA test is neither your last nor your most important. Depending on your age and your current PSA number, the question is how much, and how fast, subsequent test numbers increase. Researchers are busy determining just how much velocity is normal. (Some researchers say a speed bump of more than 0.25 in one year for a 40-year-old man should prompt concern.) Every man generates a history of data points his doctors can interpret in light of the research.

4. There ' s more than one kind of PSA to measure . Enlarged but noncancerous prostates usually release "free" PSA that circulates through the body, while PSA produced by cancer cells tends to attach itself to proteins in your blood. By considering the ratio of the types of PSA, as is done by looking at the ratio of bad to good cholesterol for heart disease, doctors can offer you better advice about your risk and what you should do next.

5. The younger you are, the more meaningful the PSA test. Older prostates tend to get bigger and put out more PSA, complicating interpretation. Higher PSA levels at a younger age are an indicator of elevated risk and call for closer monitoring of factors like your PSA velocity. At the same time, prostate cancer therapies are most effective and sparing of function when the cancer is at an early stage.

6. PSA numbers reveal your prognosis and are critical in follow-up. If you do develop a serious form of prostate cancer that requires aggressive treatment, your PSA levels prior to treatment will help your medical team determine the risk of recurrence. It's one factor among many others, such as how the tumor looked under the microscope after surgery, but the latest studies show it's of real value. After surgery to remove the prostate, the PSA test is even more critical: Detection of extremely minute levels can signal cancer recurrence. The earlier doctors know the cancer is back, the earlier patients can decide about secondary treatments like radiation and hormonal therapy.

7. For now, PSA is the best we've got. Scientists are looking hard for a better "biomarker" than the PSA, ideally one that doesn't require so much deliberation. Candidates are surfacing, but they require more proof. Physical measures like the prostate's size can be misleading, as Mayo Clinic researchers reminded us this week. Studies show that a digital rectal exam plus a PSA test is the surest way to pick up prostate cancer. But if you've got to pick only one test, PSA is still the best.

Tags: prostate cancer

Woodbridge Relay for Life, May 15-16,2009

Support “Relay for Life”

The next Woodbridge “Relay for Life” will be May 15-16, 2010. Planning is well under way and teams of participants are forming. “Relay for Life” is a great way to join together in the cause of fighting cancer and is also a special way to celebrate our “Survivorship.”

Since Jim Kearns has advanced prostate cancer and his son and two grandsons are at significant risk, he has formed a team with them. They call themselves the “Galway Boys.” “Galway” for the county in Ireland where the Kearns family originated and “Boys” in note of the risk the boys in the Kearns family have. According to their team page, their focus is on “the fight against prostate cancer.” And they welcome “members of the local chapter of ‘Us TOO International’ and others to join them.

The “Galway Boys” home page is located at: http://main.acsevents.org/site/TR?pg=team&fr_id=24958&team_id=561179

You can join the “Galway Boys,” donate via the “Galway Boys” team, start your own team, join another team (Jim Viggiani also has a team), or participate or donate as an individual. Whichever option you choose, please support “Relay for Life.”

For more information, contact Jim Kearns on 703-670-7440 or via e-mail at: jkearnsjr@verizon.net.

STORY HIGHLIGHTS

• Spokeswoman confirms Andrew Lloyd Webber has prostate cancer
• Condition in its "very early stages," according to spokeswoman
• Award-winning composer has produced more than a dozen musicals

(CNN) -- Andrew Lloyd Webber, the award-winning composer and producer of more than a dozen musicals including "The Phantom of the Opera" and "Cats," has been diagnosed with prostate cancer, a spokeswoman said Sunday.

"The condition is in its very early stages. Andrew is now undergoing treatment and expects to be fully back at work before the end of the year," the spokeswoman said in a written statement from the London-based public relations firm Brown Lloyd James. They released no further details.

Dr Samadi Recommends PSA Screening,

NEW YORK, NY--(Marketwire - November 10, 2009) - In a recent New York Times article, the American Cancer Society (ACS) ignited a major controversy over the benefits of cancer screening, specifically with regards to their breast and prostate cancer guidelines. In the article, Dr. Otis Brawley, chief medical officer of the ACS, responded to a study in the current issue of the Journal of the American Medical Association. The study, conducted over the last 20 years of screenings for breast and prostate cancer, concluded that detection of early stage disease nearly doubled for both cancers, but this early detection did not result in more patients being cured.

Dr. Brawley shared his conclusion that current cancer screening methods are not perfect. He further suggested that the advantages of screening guidelines might have been exaggerated. A subsequent clarification from the ACS stated that screening should continue to be done, but patients need to understand that current screening methods are not certain.

While the ACS is continuing to research their cancer screening guidelines, they are not changing them just yet, and neither is Dr. David Samadi, Chief of the Division of Robotics and Minimally Invasive Surgery in the Department of Urology at The Mount Sinai Medical Center. Dr. Samadi's recommendation has and will always be to encourage regular prostate cancer screenings for men over the age of 50. For those men with a family history of prostate cancer, the recommended age drops to 40. "This is no longer an old man's disease," said Dr. Samadi.

Dr. Samadi has long acknowledged that there is no perfect screening method for prostate cancer. And while the ACS does not recommend prostate-specific antigen (PSA) testing for all men, because many studies have determined that the PSA has not been successful in preventing prostate cancer deaths, it does suggest that men make an informed decision about prostate cancer screening with their doctor. Dr. Samadi wholeheartedly agrees with this suggestion, and continues to advocate prostate cancer screening, particularly in men who have known risk factors.

As an oncologist who is also an expert in open, laparoscopic and robotic surgery, Dr. Samadi does not rely on the PSA test alone in making a diagnosis of cancer and prescribing treatment. He conducts an individualized analysis of his patients utilizing a combination of markers, including digital rectal exams and Gleason scores. Even normal scores in these exams can be used as baselines to monitor future fluctuations that can indicate prostate cancer in its early stages.

"Patients who partner with their doctor to monitor these fluctuations and any other risk factors can successfully stay ahead of this disease," said Dr. Samadi, who has successfully performed over 2,100 robotic prostatectomy surgeries. Cancer grows at different rates, but Dr. Samadi believes that a diagnosis of prostate cancer is not necessarily a death sentence. However, he advocates surgery because it is only by removing the prostate that the cancer range, stage and rate can be fully ascertained.

In his own response to the controversial study, Dr. Samadi noted that the study, which took place over the last 20 years, would have a radically different outcome in today's world of cancer treatment. Due to advances in technology and surgical experience, robotic surgery has become the ideal treatment option as it is less invasive than the older modalities, and provides the surgeon a higher level of magnification and mobility. This results in cure rate of over 95%, along with reduced rates of the dreaded side effects of prostate surgery, such as impotence and incontinence.

If left untreated, prostate cancer can spread outside of the gland, making treatment and recovery more complicated and requiring follow-up surgeries. These end up increasing healthcare costs. Dr. Samadi believes in prostate cancer screening and treatment because it's effective. He maintains that there have been definitive decreases in advanced-stage cancers and age-specific prostate cancer mortality rate in the "PSA screening era." This is why Dr. Samadi asks: "Why take a chance with a silent killer when a proactive approach can reduce healthcare costs and save your life?"